This is a 64 year-old male who has had a decline in function over the
last 5 weeks. His wife gives most of the history. Symptoms include fatigue,
mild headache, confusion, and trouble reading. He had a doctor’s
appointment later this week to check this out.
This morning while at the breakfast table, he yelled, fell out of his
chair and had witnessed shaking. Positive urinary incontinence. His wife
believes it lasted only 20 seconds because she didn’t have time
to make it to the phone to call 911.
ROS positive for low appetite, 10 lbs weight loss, and a chronic cough
2. L4 laminectomy 1992
6. Right carotid endarterectomy 2001
1. Simvastatin 40mg qd
2. Omeprazole 40mg qd
3. HCTZ 25mg qd
4. Saw palmetto
5. ASA 81mg qd
6. Tylenol prn
Allergies: PCN - rash.
Family History: Father died of lung cancer at age 62.
Mother alive with Alzheimer’s. No brother or sisters.
Social History: Smokes 1/2 ppd now. Total 60 pack-years.
Occasional alcohol. Lives with wife in Kent. Retired machinist from Boeing.
BP 152/94 HR 92
General: Bruise over right eye. Carotid auscultation
normal. Scar right neck.
Mental Status: Sleepy. Knows name. Confused about the
day and date. Off by 5 years. Hospital, but not which one.
HEENT: PERRLA. EOMI. Visual fields probably show a right
field defect when he can concentrate. Fundi normal. Face normal except
for the bruise. Tongue midline, but trauma on the right.
Motor (Power/Tone/Bulk): 5/5 all.
Sensory: Can’t accurately test.
Reflexes: 1/4 at the biceps, 2/4 triceps, 1/4 wrists,
2/4 knees, 1/4 ankles. Both sides equal and toes downgoing to plantar
Coordination: FNF and HKS normal.
Gait: Mild ataxia that improved as he went down the hall.
Abnormal Movements: None.
Other Organs: Occasional expiratory wheeze on the left.